Tuesday, January 03, 2006

The "Culture of Life" Is Really the Culture of Money

There is a smarmy little article in Slate written by Steven E. Landsburg that takes the position that it was compassionate for a hospital in Texas to unhook a terminal cancer patient from her ventilator when her family could not come up with the money to pay her medical bills.

Landsburg's astonishingly stupid argument is that the (now dead) patient, Tirhas Habtegiris, before she became ill, would not have wanted to use the cost of ventilator insurance ($75 for a lifetime of insurance, according to Landsburg) to be kept on a ventilator; she would have preferred to use that money to buy milk, or pay for an annual physical. Therefore, Landsburg concludes that true compassion would have required that Habegiris be given that money for what she wanted, not for what others thought was best for her.

I kid you not.

Bloggers, most prominently "YucatanMan" at Daily Kos, are appalled because "economic considerations," as opposed to what the bloggers call "compassion," drove the decision to unplug Ms. Habtegiris. I conclude that YucatanMan either doesn't understand what an economic consideration is or doesn't understand what compassion is, because in fact the two are not in conflict.

Here, for the edification of bloggers everywhere, is an example of an economic consideration: If you ask people -- and especially poor people -- what their most dire needs are, you'll find that "guaranteed ventilator support" ranks pretty low on the list. OK, I haven't actually done a survey, but I'm going out on a limb here and predicting that something like, say, milk, is going to rank a lot higher up the priority list than ventilator insurance.

In fact, I'll go further. The back of my envelope says that a lifetime's worth of ventilator insurance costs somewhere around $75. I'm going to hazard a guess that if, on her 21st birthday, you'd asked Tirhas Habtegiris to select her own $75 present, she wouldn't have asked for ventilator insurance. She might have picked $75 worth of groceries; she might have picked a new pair of shoes; she might have picked a few CDs, but not ventilator insurance.

She might even have picked something health-care related—a thorough physical exam, or, if there were better markets for this sort of thing, $75 worth of health or disability insurance. I doubt very much, though, that with $75 to spend, she'd have chosen to insure against needing a ventilator as opposed to any of the other minor and major catastrophes to which we mortals are susceptible.

Now let me remind you what "compassion" means. According to Merriam-Webster Online (which, by virtue of being online, really ought to be easily accessible to bloggers), compassion is the "sympathetic consciousness of others' distress together with a desire to alleviate it." By that definition, there is nothing particularly compassionate about giving ventilator insurance to a person who really feels a more urgent need for milk or eggs. One might even say that choosing to ignore the major sources of others' distress is precisely the opposite of sympathetic consciousness.

There is room for a great deal of disagreement about how much assistance rich people should give to poor people, either voluntarily or through the tax system. But surely whatever we do spend should be spent in the ways that are most helpful.

Therefore there's no use arguing that the real tradeoff should not be ventilators versus milk but ventilators versus tax cuts, or ventilators versus foreign wars. It's one thing to say we should spend more to help the poor, but quite another to say that what we're currently spending should be spent ineffectively.

This is not to deny that the health-care system needs a massive overhaul; it does. But that's not the issue on the table here. The issue is: Given the current system, should or should not the federal government (or Baylor Medical Center, or somebody) effectively guarantee that nobody will ever die for lack of a ventilator? In other words, should poor people be given ventilator insurance?

The bloggers at Daily Kos say yes. But for the same cost, we could give each of those people a choice between ventilator insurance on the one hand or $75 cash on the other hand. If it turns out that I'm wrong and they all want the ventilator insurance, so be it. But why not at least ask them?

You can't do that with every government service. You can't offer people a choice between police protection and its cash value, because police patrols tend to protect entire neighborhoods at once, not just specific individuals. You might not want to offer people a choice between a flu vaccine and its cash value, because you'd really prefer to have vaccinated neighbors. But critical life support isn't like that; the benefits are targeted to specific individuals. There's no reason those individuals shouldn't be allowed to choose different benefits if they want them.

Tirhas Habtegris would probably have taken the cash. Then she'd have gotten sick and regretted her decision. And then we as a society would have been in exactly the same position we were in last week—deciding whether to foot the bill to keep Ms. Habtegris alive a little longer.

Landsburg's argument is absurd on its face; but as a response to YucatanMan's post, it's also something of a non sequitur. The Daily Kos diarist was specifically contrasting Bush's lack of concern for the "culture of life" when he signed that Texas law to his repeated invoking of the "culture of life" when he intervened in the case of Terri Schiavo. The same George W. Bush who cut his vacation short to fly back to Washington to sign a bill forcing the Florida state courts to review their decision regarding Terri Schiavo also signed the Texas law that allows hospitals to pull life support for patients without the means to pay for their care if there is no hope of recovery. Furthermore, Bush accepted the "no hope for recovery" standard to justify ending life support for indigent patients, but rejected that same premise in the case of Terri Schiavo. Indeed, his underling, Bill Frist, ignored medical common sense and the judgments of Terri Schiavo's personal physicians, and made long-distance diagnoses without having seen or examined Schiavo, to buttress his and Bush's insistence that there is always hope for recovery, no matter what the doctors say. Clearly, this same conviction does not come into play when the patient is poor and African, even though terminal cancer patients have also been known to go into remission. (See Lance Armstrong for more on this.)

So it's not about making choices between milk and ventilator insurance when deciding how to spend public money. It's about spending public money at all, and how the value of a human life changes with regard to the presence or absence of that factor.

YucatanMan makes another point, which Landsburg ignores as well. Tirhas Habtegiris knew she was going to die, and soon. She did not have any false hopes of recovery. Her major reason for wanting to stay on life support was so she could see her mother once more, and say goodbye to her. The 10 days that Baylor gave Habtegiris's family to make alternative plans for her, were not enough time to get her mother from Africa to Texas.

THIS is the true face of "compassionate conservatism" and of the phony "culture of life." ...

...Tirhas still responded and was conscious. She was waiting one person.

"She wanted to get her mom over here or to get to her mom so she could die in her mom's arms," says her cousin Meri Tesfay.

Ten days was not enough time, they say, to get a mother from Africa to America.

The family and hospital desperately tried to get Tirhas moved to a nursing home but they say no one would take her.

"A fund issue is what I understand. Because she is not insured and that was the major reason the way I understood it," Salvi said.

A statement from Baylor Plano disputes that and says the hospital did its best to comply with the family's wishes in every way.

Still, on the 11th day, Tirhas Habtegiris was taken off the respirator and died.

A dying person's last request: To die with her mother by her side. Yet, "economic considerations" are more important in Texas than compassion. ...
After the fact, the hospital claims they were willing to help bring the mother from Africa, but the family here in Dallas says they were told time had run out. Yes, the hospital was willing to help, but only within 10 days. Otherwise... the bill.

Tirhas Habtegiris would not have recovered from her cancer. There is no dispute of that. But... just to see her mother one more time. That was all she asked. And the hospital allowed 10 days before treatment was discontinued.
Recall the abject hypocrisy of Schiavo: Bush rushed back to Washington (more than he did for New Orleans) to sign the Schiavo Federal Court review legislation. But, Tirhas Habtegiris died quietly, died for 15 minutes, without anyone knowing, without politicians manipulating her life and death, never uncared about within the phony "culture of life."

And she died without seeing her mother one last time.

It's not about ventilator insurance. It's about a hospital that is not willing to foot the bill for a few extra days to give a dying young woman's mother a chance to get to the United States so she can be with her daughter when she dies. It's about a president who, when he was governor of Texas, signed a law that allows hospitals to do exactly what Baylor did.


Jon Swift said...

I thought Steven Landsburg's Slate article was brilliant and it gave me some ideas of my own: http://jonswift.blogspot.com/

Anonymous said...

I first saw the Slate article and thought it was flawed. He got so simplistic in his argument. Ask any poor family the question: Food, or health insurance, and they're going to choose to feed their family first because if they don't feed their family, they're obviously not going to survive. Irritating argument. Granted, artificially extending a life CAN be UN-compasisonate, but she just wanted to die in her mother's arms. She didn't want to be hooked up forever. Can you imagine struggling to breathe in those final 15 minutes? HOw much more comfort would she have had if she could have looked into her mother's eyes while knowing she was taking her last breaths. You can't play the compassion card there.